1114902673 NPI number — PAUL FRANK GROSCHEL PT

Table of content: PAUL FRANK GROSCHEL PT (NPI 1114902673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114902673 NPI number — PAUL FRANK GROSCHEL PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROSCHEL
Provider First Name:
PAUL
Provider Middle Name:
FRANK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114902673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16515 MERIDIAN E
Provider Second Line Business Practice Location Address:
STE 202B
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98375-6251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-840-5511
Provider Business Practice Location Address Fax Number:
253-840-0835
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT00007865 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7098254 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1447234943 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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